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Purpose: The purpose of this survey was to examine compliance of worksite health and fitness facilities with the American Heart Association/American College of Sports Medicine (AHA/ACSM) recommendations for cardiovascular screening, staffing, and emergency policies for health and fitness facilities.

Methods: A survey was developed and sent to 529 worksite health and fitness facilities.

Results: A total of 221 surveys were returned (42% response rate). Twelve percent of facilities had no staff supervision. Among facilities with staff, 12% were not certified in basic life support, and 6% had no national professional certification. Ninety-two percent of facilities followed a health history screening policy although 13% of these facilities administered it irregularly or not at all. Of a total 187 responding facilities, 122 (65%) defined “at risk” as two or more risk factors for heart disease. Of these, 97% either required or recommended new members obtain physician clearance before participation. Four (3%) responding facilities did not require physician clearance. Twenty-five percent of facilities experienced at least one emergency that required ambulance support in the previous year.

Conclusion: Although this was a low response rate, most responding worksite health and fitness facilities appear to be in compliance with the AHA/ACSM recommendations yet have inconsistencies in some specific practices. There appears to be a need for further consistent implementation of these recommendations into worksite settings.

The American Heart Association (AHA) and the American College of Sports Medicine (ACSM) published a joint statement on recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities (1). This highlighted an important area of the ACSM health/fitness facility standards and guidelines. Much of the justification for the AHA/ACSM joint position statement was based on studies documenting the potential cardiovascular risk during moderate to vigorous exercise in persons with known or occult coronary heart disease (CHD) (1–4,7–10). Other limited studies have documented the medical preparedness and prevalence of emergency events in physicians’ offices and at a medical center worksite health and wellness facility (4,5).

Little is known, however, about the screening practices and compliance to the AHA/ACSM recommendations for health and fitness facilities beyond the scope of Massachusetts. To our knowledge, no other studies have assessed the emergency preparedness of worksite health and fitness facilities and the level of education and certification of staff. The purpose of the present study was to assess the compliance of worksite health and fitness facilities to the 1998 AHA/ACSM recommendations with respect to cardiovascular screening procedures, staff qualifications, and emergency preparedness.

METHODS

Facility recruitment.

A total of 529 American Worksite and Health Promotion (AWHP) members were randomly selected from the AWHP membership directory (every sixth member) in August 1999. Questionnaires were sent to facility managers (or closest person in charge) who were asked to complete the survey. The survey (Fig. 1) was designed to assess various aspects of a health and fitness operation including staffing, health history screening, emergency procedures, and other background information. Questions were based on a previous survey sent to Massachusetts’ facilities and ACSM standards, as AWHP does not provide such recommendations (3). Postcard reminders were sent to nonrespondents after 6 wk. Phone calls were made after 10 wk to facilities that had not responded, and the survey was resent. Written informed consent was obtained from all respondents.

RESULTS

A total of 221 surveys were returned of 529 sent (42% response rate). The geographic distribution was: north central (19.9%), northeast (26.7%), mountain/western (15.5%), south central/southwest (18.4%), southeast (17.9%), and international (1.5%).

The mean number of members per facility was 1024 ± 1644 (range 7–14,000, median = 600). The mean size of facilities was 10,381 ± 13,767 ft2, (range 350–100,000, median = 6650). The ratio of members per ft2 was 1:10. Mean staff per facility was 5.9 (range 1–49). The mean number of members per staff was 171. Staff per square foot ratio was 1: 1730. Thirty-five percent of facilities allowed only employees to participate. Eleven percent of facilitieswere open to employees, spouses, retirees, and the community. The remaining 54% were open to employees and spouses, and/or retirees only. The mean cost of an annual membership was $109 ± 139 (range $0–$975).

Among responding facilities, 88% had onsite staff supervision, whereas 12% did not. Of all the staff included in the study (1302), 62% of staff were employed full-time (802) and 38% (500) were employed on a part-time basis. Three facilities (1%) had staff with no formal education beyond high school (bachelors, masters, or doctorate degrees), whereas 13 facilities (6%) employed staff with no professional certification (for example ACSM or ACE). Among staff who had achieved professional certification (not including BLS/CPR), the type of certification varied (Table 1), with 25% of staff certified by ACSM. With respect to basic life support (BLS) or cardiopulmonary resuscitation (CPR) training, 88% of staff were certified.

Ninety-two percent of facilities had a written policy statement addressing health history screening, whereas 8% had no health screening policy. Among facilities that used a health screen, 48% used a self-developed questionnaire (Table 2) of which its origin or basis was unknown. Eighty-seven percent of facilities that used a health screening questionnaire administered it to new members all of the time. Thirteen percent of facilities administered it irregularly, or not at all, to new members.

The health history-screening questionnaire was administered in 50% of facilities by staff with a college degree. Other facilities varied as to who administered the health-screening tool (Table 3). Similarly, staff with a college degree most commonly reviewed the questionnaire (Table 4). In 9% of facilities, the health-screening questionnaire was reviewed by a desk person or a staff person without a college degree, and 4% of facilities responded with “other.” The frequency that the health history screening was administered is shown in Figure 2.

Seventy-five percent of facilities required physician clearance for members that they identified as “clients at risk for heart disease,” and 18% recommended clearance. Two percent did not require or recommend physician clearance. Sixty-five responding facilities (35%) defined “at risk” as one or more risk factors. Of these, all facilities either required or recommended physician clearance. A total of 122 (65%) responders defined “at risk” as two factors or more. Of these, 118 (97%) either recommended or required physician clearance, and 4 (3%) did not require clearance. For clients with a known medical condition, 82% of facilities required physician consent (or exercise was not permitted), whereas 12% recommended physician consent. Six percent said that consent did not affect exercise participation. For new members with hypertension, 80% of respondents required physician consent to participate, whereas 20% did not.

Ninety-four percent of facilities reported that emergency procedure practices were part of their staff training/orientation, whereas 6% said it was not. Twenty-six percent of responding facilities did report practicing their procedures at least quarterly; however, 15%, 37%, and 22% reported practicing their emergency procedures semi-annually, annually, and every 1–3 yr, respectively. Fourteen percent of facilities did have defibrillators onsite and used them in training. However, 75% of facilities reported neither having a defibrillator onsite nor having it as part of their training. A further 9% had a defibrillator but did not have it as part of their emergency training, whereas 2% of facilities had no defibrillator but did have access to one during training. Twenty-five percent of facilities reported at least one emergency that required ambulance support in the past year. One facility reported 10 such emergencies.

DISCUSSION

Although multiple follow up attempts and strategies were employed, only 42% of facilities responded to the survey. Therefore, the discussion is based only on those responding facilities. It is difficult to infer these results to the general health and wellness facility population, particularly considering that nonresponders of this survey are even more likely to be noncompliant with such standards. Although the results of this study are consistent with a previous study conducted in Massachusetts (response rate of 54%) on health and fitness facilities (with the majority of centers seemingly adhering to the ACSM guidelines and principles concerning written policies and screening) (4), compliance with some of the set policies and standards is less than optimal.

Twenty-five percent of staff were certified by the ACSM and 6% did not have any national professional certification. Although most staff did possess BLS/CPR certifications, 12% did not. In addition, 12% of facilities reported no supervision. This is concerning for two reasons. It appears that although 94% staff are professionally certified, only 88% possess a BLS/CPR certification. Second, the potential for a medical emergency always exists, and 25% of facilities in this study experienced at least one medical emergency that required an ambulance in the previous year. The AHA/ACSM statement recommends that all supervisory staff should have a national professional certification and be certified in BLS. AHA/ACSM also recommends quarterly emergency practices; however, in the present study, only 26% of the respondents fulfilled these requirements. Interestingly, AWHP does not provide certification and professional guidelines.

The ACSM suggests that “a facility must offer each adult member a preactivity screening that is appropriate to the physical activities to be performed by the member”(6). In addition, the AHA/ACSM joint statement recommends that “all facilities offering exercise equipment or services should conduct a cardiovascular screening of all new members and/or prospective users”(1). Seventeen facilities in the survey (8%) did not have a health history screening policy. Of those facilities that did have a health history screening, 24 (13%) administered it irregularly (Fig. 2).

A large proportion of facilities (48%) developed their own health-screening questionnaire. It is understandable that facilities may wish to develop their own screening questionnaire due to the individual nature of their practice; however, it is hoped that they are based on already established questionnaires or practices such as the PAR-Q (23% of respondents), the AHA/ACSM screening questionnaire (22% of respondents), or an M.D. physical (5% of respondents). Unfortunately, the results could not confirm whether or not this was the case. In 9% of facilities, the health history screening was reviewed by desk personnel or staff having no college degree. Whether or not new members are being adequately screened is difficult to determine, but these data leave open the possibility that they may not be in some cases.

According to the AHA/ACSM recommendations, fitness facilities (like those in the present survey) offer high-intensity physical activity (1). This is why the recommendations ask for physician clearance for those with two or more risk factors. ACSM guidelines do not call for physician clearance for moderate risk groups (older or with two or more risk factors, but without signs, symptoms or known disease) if they plan to engage in moderate intensity physical activity.

In the present study, it is interesting to note that the criteria for determining “at risk” clients varied among survey responders. Thirty-five percent of facilities used a threshold of only one risk factor to identify “at risk” clients, despite the fact that ACSM requirements state two risk factors must be present to classify an ‘“at risk” client (1). These results suggest an opportunity for further education and communication on identification of “at risk” clients by ACSM.

The sample from which the study population was selected was from the AWHP membership directory. Ten members returned the survey because they were not associated with a facility. This may explain one possible reason for the low response rate. In addition, these worksite settings (which include members of this organization) may not be a true reflection of all health and wellness facilities in the United States and worldwide. Therefore, the results of this survey may not be generalizable to commercial and other types of health/fitness centers.

The 42% response rate is an acknowledged limitation of this study. In addition, the responses were by self-report. The results presented here may underestimate the level of noncompliance among all worksite health and fitness facilities because facilities that respond may be more likely to be compliant with current recommendations. Further, these data in no way represent practices of public health clubs.

Most responding worksite health and fitness facilities followed recommendations issued by the AHA/ACSM. However, the results of this study underscore the need for further implementation of the AHA/ACSM recommendations into worksite settings.

We gratefully acknowledge Anita Prazak and all staff at the Dan Abraham Healthy Living Center for their assistance with the data collection for this project.

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